Welcome to the EMU Goodness for February
Cardiac Arrest
EMU is my baby, so I can rant when I want to. And I want to. I am against badge courses – if we do this stuff all the time so we do not need to take courses with radiologists who see one cardiac arrest every time the Cubs win a World Series. I recently took ACLS and heard about ROSC – you’ve got to freeze these folks (see last month) and we know that ain’t true anymore. Now you’ve got to know this about epinephrine – it isn’t the lifesaver we thought it was. Yes, it will give you ROSC, but these patients have a higher mortality post CPR and less functional recovery. It is most often seen after VF. This is thought – as we mentioned in the past – to be due to the vasoconstriction it causes in the heart (Curr Opin Card 28(1)36). So, my ACLS course is a five minute one – you are all welcome to take it and get a card – it involves teaching you about giving electricity. That’s it. What I am interested in knowing about – Scott – why doesn’t the use of push dose epi/ epi drip cause the same problem?
TAKE HOME MESSAGE: Epi can cause more mortality in cardiac arrest. So can ACLS.
Electrical Storm
The treatment is pretty straight forward (but can still be a nightmare), but you should know about this syndrome – it is called electrical storm. This is when a patient with an ICD gets breakthrough VT – usually manifested by multiple shocks. (Storm can occur in patients without ICDs too! (See http://litfl.org/1ftWiGc ) Ablation may be necessary but in the interim consider beta blockers (they increase fibrillation threshold and reduce sympathetic tone), amiodarone, or sotalol (ibid p72). Chris, my peer reviewer, points out: cervical ganglion blockade has also been described – perhaps he can let our readers know how to do this. I like procanimide- but this was not mentioned here. What does Amal Mattu hold? We’ll never know .
TAKE HOME MESSAGE: Remember electrical storm – it is breakthrough VT in a patient with an ICD.
Phlebotomy and Metabolic Syndrome
Incredible theory – I think it is too wild – but it is a fun theory. If you are a practical sort, then you might as well skip this paragraph. Iron impairs glucose metabolism, increases insulin resistance, endothelium dysfunction, and coronary artery response. So maybe that is what makes metabolic syndrome what it is, and these folks had significant improvement in diabetes, HTN and lipids after- blood letting (BMC 10:53). To me this may be of interest to forestall giving people iron supplements without good reason. TAKE HOME MESSAGE: Iron reduction – via phlebotomy- may improve metabolic syndrome Here is a leech to help you think about how to treat these folks
and here is Reggie Leach – a forward on the 1974 Flyer’s Stanley cup winning team. He does not suck blood.
Hey it is time for quotes – we have been funny the last few months, but it is time to return to cool – here are some of the neatest detective quotes.
“From 30 feet away she looked like a lot of class. From 10 feet away she looked like something made up to be seen from 30 feet away.” Raymond Chandler, *The High Window*
“Dead men are heavier than broken hearts.” Raymond Chandler, *The Big Sleep*
The Cochrane Review
Yea, so there is this thing called EBM and Cochrane is the temple where these folks pray. The problem is Cochrane is as decisive as my wife. (Oh don’t start that again)
Ok, I used to be indecisive, now I am not sure. They usually come to no decision, and say stuff like – more studies are required – however I have distilled down some interesting ones that may at least question the holy cows. Firstly – do you need antibiotics after a tooth extraction? I promised you this last month. The answer is that this will lessen pain, and protect somewhat from dry socket, but I am not sure how. All these studies, however, were done on healthy folks with extraction of wisdom teeth, (third molars) and so we really do not know. The NNT is 12, but what is the NNH? For people with problems with fighting infection problems (such as DM), the NNT may look better. (Cochrane 3811) Ketamine for asthma in kids? That has got to be a slam dunk, no? Well, there was only one study on non-intubated kids and none on intubated and it showed….no benefit. ( ibid 9293) Magnesium – is Rick still reading? Inhaled Magnesium will help – but only in severe asthma – just like IV (although a lot less evidence for inhaled) (ibid 3898).
TAKE HOME MESSAGE: Antibiotics may help in extracted teeth, asthma may not respond to inhaled mag or IV ketamine.
“I needed a drink, I needed a lot of life insurance, I needed a vacation, I needed a home in the country. What I had was a coat, a hat and a gun. I put them on and went out of the room.” Raymond Chandler, *Farewell, My Lovely*
“It was a blonde. A blonde to make a bishop kick a hole in a stained-glass window.” Ibid
Outcomes in ICH Patients Boarding in the ED
Oh, this is a sensitive subject. The Israeli Ministry of Health has just decided that we are responsible for patients boarding in the ED – this may seem obvious in some countries but it takes the pressure off of the wards to send patients home. Besides, I learned EM; I do not feel that I have enough experience to do inpatient medicine. So these neurosurgeons come around and state well, leaving patients with ICH in the ED are not associated with worse outcomes (Neurocrit Care 17(3)334). These patients do poorly no matter what so this is really a study that can not say much. At least they admit that in many medical conditions it does make outcomes worse.
TAKE HOME MESSAGE: ICH patients do not do any worse if they board in the ED.
“The girl gave him a look which ought to have stuck at least four inches out of his back.” Raymond Chandler, *The Long Goodbye*
“He looked about as inconspicuous as a tarantula on a slice of angel food cake.” Ibid
Pediatric Orthopedics
I really wanted to use this article, however it is 27 pages long and it is from 2011- I just missed it when I wrote those EMUs. It is all about kid’s orthopedics like toritcollis, flat feet, genu vara, clubfoot and the like. If you like kids then you should get this article (Curr Prob Ped Adol Health Care 41(1)2
“You’re broke, eh? I been shaking two nickels together for a month, trying to get them to mate.” Raymond Chandler, *The Big Sleep*
“She lowered her lashes until they almost cuddled her cheeks and slowly raised them again, like a theatre curtain. I was to get to know that trick. That was supposed to make me roll over on my back with all four paws in the air.” Ibid
Clinical Quiz 1
Clincial quiz time, does anyone ever get these without looking at the answer? Here is a lad who is 68 with four days of fever and discharge from the eyes. He has tender nodules on the skin. He has ulcerative colitis for which he is receiving azithoprine. Hint: this is not erythema nodosum. Another hint- we have had this before as a quiz on EMU but it was six years ago. Here is a picture of the nodules (JAMA Optho 131(6)791)
Migraines and Triptans
Hey, just a reminder – 25% of migraines will be non-responders to triptans. (Ann Emerg Medi 62(10) 11) While I like doperidol/haldol and steroids and NSAIDS – decapitation is usually curative of migraines.
“Neither of the two people in the room paid any attention to the way I came in, although only one of them was dead.” Ibid
“He snorted and hit me in the solar plexus. I bent over and took hold of the room with both hands and spun it. When I had it nicely spinning I gave it a full swing and hit myself on the back of the head with the floor.” Raymond Chandler, *Pearls are a Nuisance*
IV Fluids for Patients with Renal Colic
Well does it or doesn’t it? Fluids for renal colic- according to Stu Swadron from EM RAP and USC (and an EMU subscriber) – these cause more spasm. This EBM series saw only two reasonable studies and they didn’t help anything- stone mobilization, need for analgesics- nothing. (Ann Emerg Med 62(1)36) Of course if the patient has been vomiting all the time – I would agree that fluids will help. I maintain however, that the kidney knows that one side is stuck and will pour all the fluids to the other side – but that is just me.
TAKE HOME MESSAGE: There is no good evidence that fluids do anything in renal colic.
“The wet air was as cold as the ashes of love.” Raymond Chandler, *Farewell, My Lovely*
“Mostly I just kill time,” he said, “and it dies hard.” Raymond Chandler, *The Long Goodbye*
Do a good eye exam!
I really do not pay much attention to the eye exam – maybe I should according to this article. Sometimes it is obvious- a fixed dilated pupil can be aniscoria from an operation for cataract, it can be due to medications but it can also be do to a palsy of the third nerve which can be a sign of an aneurysm of the posterior communicating artery. Of course there will be an outward deviation of the eye. Horner’s syndrome can cause a small pupil and face pain and can be from a carotid dissection. Infants can have a Horner’s syndrome from a neuroblastoma (classically Horner’s is miosis, anhydrosis (which may be hard to measure) and ptosis which may be subtle). Now the swinging light test - which I never do – can help diagnose optic neuritis, tumor compression or advanced glaucoma. (CMAJ 185(9)e424)
TAKE HOME MESSAGE: Yeah you should check the eye- especially if there is ptosis or anisocria- but the swinging light test should be part of the exam.
“Most people go through life using up half their energy trying to protect a dignity they never had” ― Raymond Chandler
“I don’t mind if you don’t like my manners. They’re pretty bad. I grieve over them during the long winter evenings.” ― Raymond Chandler, *The Big Slee*p
Outcomes in Admitted Chest Pain Patients
This study looks at what happens to those admitted to the hospital with chest pain. If they were not admitted to the CCU and did not infarct and had no known concurrent IHD- they did pretty well (BMC Med 10:58). However this all depends on the population in this retrospective study. Admission to a CCU does not necessarily mean heart disease- in some places everyone with chest pain gets admitted to a cardiac unit, some get admitted to a step down unit and of course how many died and had other chest pathology (like PE or aneurysm) are also a consideration. Many get readmitted – about a fifth – but again that doesn’t mean much. In short -
TAKE HOME MESSAGE: Chest pain patients without concurrent IHD generally do well in this meta analysis.
“I sat down on the edge of a deep soft chair and looked at Mrs Regan. She was worth a stare. She was trouble.” ― Raymond Chandler, *The Big Sleep*
“I’m a licensed private investigator and have been for quite a while. I’m a lone wolf, unmarried, getting middle-aged, and not rich. I’ve been in jail more than once and I don’t do divorce business. I like liquor and women and chess and a few other things. The cops don’t like me too well, but I know a couple I get along with. I’m a native son, born in Santa Rosa, both parents dead, no brothers or sisters, and when I get knocked off in a dark alley sometime, nobody will feel that the bottom has dropped out of his or her life ― Raymond Chandler, *The Long Goodbye*
Passive Leg Raise
Trendelenberg—well, I do not want to put this down (pun intended, but not appreciated), but it doesn’t work. So say the EBM gurus from the EMJ (27(11)877). Now, passive leg raising is a better adjunct, but this study was a meta analysis and the numbers don’t look like it helps that much. (J Clin Anesth 24(8)668) Here is how you do passive leg raising.
It is definitely more comfortable for the patient.
TAKE HOME MESSAGE: Passive leg raising is more comfortable for the patient and probably works a little better.
“She smelled the way the Taj Mahal looks by moonlight.” Raymond Chandler, *The Little Sister*
“Until you guys own your own souls you don’t own mine. Until you guys can be trusted every time and always, in all times and conditions, to seek the truth out, and find it, and let the chips fall where they may — until that time comes, I have the right to listen to my conscience, and protect my client the best way I can. Until I’m sure you won’t do him more harm than you’ll do the truth good. Or until I’m hauled before somebody that can make me talk.” ― Raymond Chandler, *The High Window*
Efficacy of the Influenza Vaccine
Yea so let’s make this quick. We know that Taimflu (ostelamvir) doesn’t work; now the influenza vaccine is in question – they contend that less than 43% of high risk groups get protection from this vaccine (high risk is defined as over 65, chronic disease, health care workers) (Lancet Inf Dis 13(1)7) This of course says nothing about protection in the general population, but what else can we do about this terrible virus that manages to out smart us all the time? Dr. Richard from Princeton – are you still reading? What do you have to say on the subject?
TAKE HOME MESSAGE: There are effectiveness issues with the influenza immunization – is nothing sacred?
“When I got home I mixed a stiff one and stood by the open window in the living room and sipped it and listened to the groundswell of traffic on Laurel Canyon Boulevard and looked at the glare of the big angry city hanging over the shoulder of the hills through which the boulevard had been cut. Far off the banshee wail of police or fire sirens rose and fell, never for very long completely silent. Twenty four hours a day somebody is running, somebody else is trying to catch him. Out there in the night of a thousand crimes, people were dying, being maimed, cut by flying glass, crushed against steering wheels or under heavy tires. People were being beaten, robbed, strangled, raped, and murdered. People were hungry, sick; bored, desperate with loneliness or remorse or fear, angry, cruel, feverish, shaken by sobs. A city no worse than others, a city rich and vigorous and full of pride, a city lost and beaten and full of emptiness. It all depends on where you sit and what your own private score is. I didn’t have one. I didn’t care. I finished the drink and went to bed.”― Raymond Chandler, *The Long Goodby*e
Shoot first, ask questions later…
I like the idea, I have been using it, but I do not think that there is good proof yet. They propose – this really isn’t science yet – that we front load antibiotics – start off with a higher dose and go down in dose as the patient recovers. (J Crit Care 28(4)341) This is similar to a article by Cunha I brought years ago that said basically start at high dosages and for short durations. We really just need to understand the nature of the beasts we are trying to kill, but this sounds reasonable.
TAKE HOME MESSAGE: Hit fast, hit strong and I am not talking about CPR but antibiotics.
“The streets were dark with something more than night.”― Raymond Chandler
“Such a lot of guns around town and so few brains. You’re the second guy I’ve met within hours who seems to think a gun in the hand means a world by the tail.”― Raymond Chandler, *The Big Sleep*
Viruses and Airplanes
This only looked at measles but the principles are the same. Air flow in an aircraft is highly efficient in preventing airborne spread of viruses- that is under normal conditions where everyone is seated (air is brought in from the outside; BTW, so using your little air nozzle is not a bad thing). Therefore current USA recommendations are concerned with those sitting within two rows of index cases with viruses. However, in the literature – there are cases of spread all the way to 17 rows away. However, people do not stay in their seats, there is turbulence with in the cabin, movement of people and equipment and this will affect the air flow patterns (Travel Med Infec Dis 10(5-6)230). OK, SARS is one thing, but in most cases, this does not seem to be a common event. 23 cases of secondary spread in a literature search going back to 1946 when technology was a lot different. So yes, you can feel safe bring your pet Ebola virus on board with you. Hey, the TSA won’t stop you.
TAKE HOME MESSAGE: Spread of pathogens in an aircraft seems to be rare.
“Hair like steel wool grew far back on his head and gave him a domed forehead that might at careless glance seemed a dwelling place for brains.” ― Raymond Chandler, The Big Sleep*
“She looked playful and eager, but not quite sure of herself, like a new kitten in a house where they don’t care much about kittens.” ― Raymond Chandler, *The Lady in the Lake*
Delivering Bad News
I cannot say that this is a definitive article but the idea is important and I would invite discussion on it. Breaking bad news is never easy – how do you do it with people with intellectual disabilities? There is still a lot to say on this but basically the article says to cut the information down to small chunks of information and add over time (Pall Med 27(1)5). Many of our patients are not classified with disability, but lack the ability to understand when you explain procedures or treatments. We also do not have the luxury of adding over time. We need a model to help us with his because most of us were pretty smart to start with (especially those who read EMU), and relating to those who are not the same level can be challenging. This also doesn’t give us much help on explaining bad news acutely PLEASE PLEASE let me know your ideas on this.
TAKE HOME MESSAGE: Intellectual disability requires special guidelines when explaining to them their medical conditions or breaking bad news.
“Who shot him? I asked. The grey man scratched the back of his neck and said: Somebody with a gun.” - Dashiell Hammett, *Red Harvest*
“Nora: “How do you feel?” Nick: “Terrible. I must’ve gone to bed sober.” ― Dashiell Hammett, *The Thin Man*
The Colors of the Rainbow
I don’t know Dr. Kevin – you got me started on colors and now there is a flood of papers on colors. In kiddies, hyperbilirubinemia clears from all tissues – except the teeth. True the DDX is long (and rather uninteresting – so see the paper if you want this) but if you see someone with green or black teeth – think about bilirubin (Ind Ped 49(12)1015). Or better yet – think that this person may just have trench mouth. Further down the list- and the body (AJEM 31(1) E5) is the famous purple urine bag which comes from Morganella , pseudomonas, klebsiella, E coli, and proteus.
Can we get shoes to match that urine bag?
TAKE HOME MESSAGE: It’s a colorful world.
“We didn’t exactly believe your story.” “Then –?” “We believed your two hundred dollars.” “You mean –’” She seemed not to know what he meant. “I mean that you paid us more than if you’d been telling the truth,” he explained blandly, “and enough more to make it all right.” ― Dashiell Hammett, *The Maltese Falcon*
Lactate
I really think this is a bunch of bull but as I once plagiarized – “everything I say is true, just some of it has not been proven yet”. Lactated Ringers (not LACTATE – but we will get to that later) or Hartmann in Europe has lactate in it (I am not sure why actually). This study wanted to say that D lactate is worse than L lactate, like in animal studies, and causes more mortality. (ibid 31(1)206) This is a retrospective study and with that, it is important to know how bad off the patients were in any case – maybe from the start they would have died – although they did succeed in taking ISS in a majority of patients. Furthermore, many patients received many types of fluids. And of course, there is no control in a retrospective study.
TAKE HOME MESSAGE: Is d lactate worse?
Brigid O’Shaughnessy: “I haven’t lived a good life. I’ve been bad, worse than you could know.”
Sam Spade “You know, that’s good, because if you actually were as innocent as you pretend to be, we’d never get anywhere” ―ibid
Propofol’s Use in Patients with Egg Allergies
Yes so we all love propofol- but it is egg based- do you need to check egg allergy? Answer – only if there was anaphylaxis to eggs (EMJ 30(1)u172).
“The boy spoke two words, the first a short guttural verb, the second - you.” Dashiell Hammett
“The face she made at me was probably meant for a smile. Whatever it was, it beat me. I was afraid she’d do it again, so I surrendered” ― Dashiell Hammett, *The Continental Op*
Rehydration in AGE
So what’s new in AGE (acute gastroenteritis) in kids? Well the ORS is getting better tasting, and NGT (zonde) rehydration is used in many countries, but rapid rehydration is the rage now. But that is only by mouth – and over four hours. IV – ultra fast may work too, we just do not know – the studies are not conclusive (or good). Odansetron – yes, zinc – no unless you live in a country where zinc deficiency is common. Probiotics are also good. Outside of Europe they like smectite or racecadotril I have no experience with this (Alimentr Pharm Ther 37(3) 289). I was surprised that they did not mention that it is rare that hydration must be given IV.
TAKE HOME MESSAGE: Probiotics, fast rehydration and odnasetron – gets that kid back to his annoying self very fast!
“You ought to have known I’d do it!” My voice sounded harsh and savage like a stranger’s in my ears. “Didn’t I steal a crutch from a cripple?” – Dashiell Hammet
Mystery Rash
OK, so missing this can be serious. And yes, we have used it in the past for clinical quizzes. The rash looks like this:
Fever, malaise, and usually it hitchhikes on to a current derm condition like psoriasis, eczema or seborrhea. It is HSV and looks like – HSV – and the treatment is – anti virals against HSV. Just be careful – it gets impetigo-nized easily and may mask the need for antivirals. (Can Fam Phys 88(12)1358).
TAKE HOME MESSAGE: HSV can cause a picture of impetigo and eczema that may become disseminated if you do not use antivirals.
Time now for one of my favorite detectives – 007.
(After a hearse flies over a cliff and explodes) “I think they were on their way to a funeral.”
(After a gangster is crushed in a car) “He had a pressing engagement.”
(After feeding the bad guy a shark gun pellet and watching him explode) “He always did have an inflated opinion of himself.”
(After harpooning someone) “I think he got the point.”
(After a villain’s death by snowblower) “He had a lot of guts.”
All James Bond
Clinical Quiz #2
However, this diagnosis will be a clinical quiz, and, yes, since I do not particularly like cardiologists – let’s see if my one cardiology readers can get this right. This Lldy is 56 with HTN and allergic alveolitis. She has chest discomfort; she has flipped T waves, Troponin T of 2.82. Echo showed an EF 40% and a mild cardiac effusion. She arrested, asystole and was resuscitated. Note that the esosinophil count was high at 55%. No parasites, no connective tissue disease, no MDS, no lympho proliferative disease, so this is??? (AJEM 31:271:e1)
(After using a villaness like a human shield while dancing)
“Do you mind if my friend sits this one out? She’s just dead.”
Dr. Goodhead: “You know him?”
Bond: “Not socially. His name’s Jaws. He kills people.”-Bond
Albuterol and Lactic Acidosis
Do I believe this? I promised we would speak about Lactate- but not just yet. The asthmatic was improving but now is dyspneic again. Well, lactic acidosis can come from medications-(metformin, catecholamine, INH, salicylates) and albuterol is apparently one of them. As such, it causes a metabolic acidosis and they must breath rapidly to blow off the acid. Sound odd? Well, our obstetricians know that ritodrine used for premature contractions can cause the same problems and is a beta two agonist.(Resp Care 57(12)2115)
TAKE HOME MESSAGE: Albuterol can cause lactic acidosis. (Actually any beta-agonist does – adrenaline infusions too).
Never Say Never Again
Largo: “Do you lose as gracefully as you win?”
James Bond: “I don’t know, I’ve never lost.”
License To Kill
Bond: “In my business, you prepare for the unexpected.”
Franz Sanchez: “And what business is that?”
Bond: “I help people with problems.”
Franz Sanchez: “Problem solver.”
Bond: “More of a problem eliminator.”
Consider…Brucellosis
We see this here. Yes, in the USA – where we all know there is the only civilized life is located in a small area
they do not see much of this, but I do and a lot of EMU readership does. Fever–usually prolonged, arthralgia, myalgia, back pain, even sacroillitis. It can also cause epididymitis – this is Brucellosis and comes from the consumption of unpasteurized animal milk and exposure to livestock. Careful – this may look like malaria at first. (PLOS Neglected disases (12)e1929) The treatment is Streptomycin and Doxy.
TAKE HOME MESSAGE: Keep Brucella on your list from prolonged fever – in kids also in the right areas of the world.
Here are a few people to help you remember: Brucellosis Lee
Brucellosis Springsteen
Brucellosis Jenner
and of course Lenny Brucellosis
On Her Majesty’s Secret Service
Draco: “My apologies for the way you were brought here. I wasn’t sure you’d accept a formal invitation.”
Bond: “There’s always something formal about the point of a pistol.”
The Spy Who Loved Me
Bond: “Mmm, maybe I misjudged Stromberg. Any man who drinks Dom Perignon ’52 can’t be all bad.”
Medical Ethics
You know some of the best ethics articles do not appear in the ethics journals. Of course, EMU spares no effort in finding them and I think I speak for everyone in pointing out how much we enjoy hearing from Ken, Knox, and others on ethics. This article appeared in the burn literature. The question is medical futility- and there are many definitions and aspects to this. They in this article on delve into the issue of not using treatments that will not help the patient (in for example – the last 100 treated with this condition) or will not return quality of life. And here is where the questions begin– yes most patients with greater than 90% tBSA burns do not survive- but some do-and they even give an example case. Second of all – is this all the doctor’s decision or does the patient have any say in the matter? He finally compares futility to (sic) pornography- we can’t define it but we ill know it when we see it. (Burns 39:851) Now this article did not go into it, but what if the benefits are there and dangers as well? And quality of life is very subjective. All I can tell you is that I think all religions that I am familiar with– do not recognize the need to increase suffering in terminal cases. But there is still a lot of gray zone. Ken? Knox? What do you have to say?
TAKE HOME MESSAGE: Futility is complicated – I believe the patients and their families and their clergy must be involved.
Bond: “Who is the competition?”
Jack Wade: “AH, an ex-KGB guy. Tough mother. Got a limp in his right leg. Name’s Zukovsky.”
Bond: “Valentin Dmitrovitch Zukovsky?”
Jack Wade: “Yeah, you know him?”
Bond: “I gave him the limp.”
Bond: “I’m looking for Dr. Goodhead.”
Dr. Goodhead: “You just found her.”
Bond: “A woman?”
Dr. Goodhead: “Your powers of observation do you credit, Mr. Bond.”
Bond: “Oh, by the way, thanks for deserting me back there.”
Agent XXX: “Every women for herself, remember?”
Bond: “Still, you did save my life.”
Agent XXX: “We all make mistakes, Mr. Bond.”
….CTS?
CTS – (JFP 61 (2) 12) – what is this – what is this??? See below – don’t miss it!
Magda: “I don’t know how to say goodbye.”
Bond: ”Actions speak louder than words…”
Felix Leiter: “I give up. I know the diamonds are in the body, but where?”
Bond: “Alimentary, Dr. Leiter…”
Critical Care Cases
No article here, but a few tidbits on ICU stuff that I encountered this week in the shock room. This is probably child’s play for Scott and Chris ( Hi Chris – how is the EMU this month? So far, so good! – Chris) but this is for those who do not get much exposure to shocky patients. Firstly, I had a patient with cardiogenic asthma – and no matter what I did – suction, inhalations, nitroglycerin – the respirator registered high pressures (note the patient was already intubated by the ambulance personnel). The saturation remained 100%. But as Scott pointed out on EMRAP- this is a problem of the pressure settings and I should’ve checked the plateau pressure and then readjusted the peak pressure until I could adequately unload her. I forgot, Scott, I am sorry. Then I had a patient who needed an IV for acute pulmonary edema treatment- who was not intubated but was pretty edematous- so what does one do? Well, you can try ultrasound, but many places do not have this, and while we do, we did not have a linear probe until this week. What about the lower extremities- well she had undergone a fem pop bypass not too long ago, no one wanted to take a chance. Intraosseus is a definite option, but then again – many folks do not have this (I do). Central line? Well, the patient was taking Fragmin so if you missed – you would have a big bleed on your hands- so femoral is your best bet because you can compress there, but then we go back to the fem pop bypass problem., Well that is a few ideas- what did I do? I found a nice juicy EJ. Here is another case- patient with HTN and DM and hypercholesterolemia, from the nursing home (although he is oriented and verbal – has old hemiparesis) comes in breathing at 40 a minute, temperature of 34.6 and lactate of 16. We of course give him fluids to lower that, but the chest film is pretty clear- and his creatinine is uncharacteristically high. We throw in a catheter – volila he has 1400 cc of fresh Ypsilanti beer in there. But the pH comes back at 6.52 – - I do not have an explanation for the low temp, but this seemed to be MALA – metformin associated lactic acidosis. He was ventilated already but here too the ventilator was not happy even when I set the respiratory rate higher on SIMV. My ICU guys advised me – right or wrong – you will never succeed to reduce the acidosis unless you give him bicarb and paralyze him and get it down with the ventilator with out his help. Is this good ICU care? Let’s hear from our ICU guys- I am just a little man.
And yes Chris replied: (Giving bicarb just means you have more CO2 to ventilate off IMO ) – most severe MALAs need renal replacement therapy – Chris
Pussy Galore: “My name is Pussy Galore.”
Bond: “I must be dreaming.”
Bond: “Do you expect me to talk?”
Goldfinger: “No I expect your to die!”
Mei-Lei: “Can I do anything for you, Mr. Bond?”
Bond: “Just a drink. A martini, shaken, not stirred.”
Letters
And letters. Ken writes from down south:
Hi Yosef
Loved the backscratcher cartoon! I need one of those. However, I suspect it will be difficult to pack in my bags and the customs officials may look askance at it.
No problem Ken - just tell the TSA folks it is a bomb.
A note about the ultrasound and vesicourethral reflux you mentioned. I was confused about a “well-done” ultrasound. The article actually mentions a “renal ultrasound” for this evaluation.
Yea, I added that- that is the flavor I got from this article – but see below for more on that.
As to your question about chlorhexidine preventing alveolar osteitis, that is still an open question, although many dentists and oral surgeons use it. A meta-analysis can be found at: Int J Oral & Maxillofacial Surg, 2012 (Oct);41(10):1253-1264 (http://www.ijoms.com/article/S0901-5027(12)00174-9/abstract).
The citation about end-of-life attitudes internationally is interesting. I agree with the authors that withholding treatment can be as or more morally problematic than withdrawing treatment. In Emergency Medicine, the issue revolves around the amount of available information. (See: Iserson KV: Withholding and withdrawing medical treatment: an emergency medicine perspective. Ann Emerg Med 1996;28:(1):51-55.). Yet, as I have seen repeatedly around the world, local laws and customs often make it nearly impossible to withdraw treatment once it is started. This can be tragic, but it demonstrates that cultures vary in their perspectives on medical ethics.
Best wishes for a Happy New Year!
Ken you too, Ken – keep those letters coming – that add so much. And now Steve Parillo who we haven’t heard from in a long time. Sad about them Eagles – huh Steve? Wait until next year!
Thanks as always, Yosef. Regarding number 6, I thought you’d like to hear a story from many years ago when US anesthesiology grads were having trouble finding jobs. The President of the Am Soc of Anesth called then ACEP pres Greg Henry to tell him that he thought anesth residents were well trained and should be able to work in EDs and take the cert exam. Greg shot back, “Let me explain something, doctor. ‘In goes the good air, out goes the bad air’ hardly constitutes appropriate training to work in an ED.”
Steven J. Parrillo DO, FACOEP, FACEP
I wrote Father Greg for more details about this, but still haven’t heard from him as we go to press. Father? Are you there? Here is Knox weighing in on the heavy ethics issue that Ken spoke about above
Saw the call-out regarding end of life ethics. Certainly agree with the directive that we learn to the extent possible the patient’s wishes as expressed by them directly (living will, etc.) or through loved ones. The statement: “What would you want if you were at the end? That is probably what most folks want too.” may be shakier ground. Substituting my own wishes for my patients in a diverse, pluralistic society is a threshold I try not to cross. Some of this is inevitable – the cognitive errors we all make – but we should guard ourselves by being aware of them.
Knox – I agree with every word- thanks for writing. Here is Scott from NY.
Yosef -
If you want to do inhaled anesthetics for your asthmatics, you are going to need to send them to the OR. That is unless you have something like the http://www.sedanamedical.com/aboutanaconda_po.php, but I have never been to a place that does. Even then there are questions of scavenging that make most folks leery.
Yes, Scott , that is what I meant- no gas passer is going to bring that contraption down to the ED and nor should he. But keep it in mind for the two statuses – asthmaticus and epilepticus. I promised you guys lactate and here is Scott’s comment on the alactemia.
As to the lactate stuff: you’ll note the linked letter, there is no reference for patients with alactemic septic shock doing words and being prone to “multi-organ failure.” That’s because there is none that I can find. Patients with normal lactate and vasopressor dependence seem to do great in the literature. References at emcrit.org/sepsis
So I wanted to get to the bottom of this so I wrote the author – a Dr. Nguyen from Loma Linda who mentioned that this idea is based on a conclusion from two of his references – but I decided to give Scott the last word – and it was a treat – read on:
So Yosef wrote to the editorial author, who by the way is a brilliant sepsis researcher, who stated the support for the statement above was ref 14 & 16 from his editorial.
Ref 14 is PMID: 22440322: Where you will find a mortality for alactemic sepsis of 20% vs. hyperlactetemia patients with a 43% mortality
Ref 16 is PMID: 2255201: Which shows a 25% mortality in the normal lactate severe sepsis group and a 58% mortality in the hyperlactatemic group.
So I’m not quite seeing where these patients do worse. If the question is will vasopressor dependent septic shock patients with normal lactates still die? — absolutely! But their outcomes will be markedly better than those with elevated lactates. Lactate is a prognostic marker in severe sepsis. Alan Jone’s work is based on the use of lactate in this circumstance and reading his LACTATE paper is elucidative. The topic of Bryant’s editorial was a reanalysis of this paper. The take-home message of that reanalysis is if you can clear the lactate to normal with your interventions, the patient does much better. If they didn’t have an elevated lactate to begin with, keep checking to make sure you are not screwing them up and the lactate is rising and they probably will do well too.
So that settles that. My only point is be careful what you read- many times conclsusions are really just expert opinion.
Thanks Scott for that discussion and thanks for helping (helping? Actually – he did everything!) us get up the the EMU website (details to follow).
And now some answers…
The answer to clinical quiz #1 was Sweet Syndrome – causes include malignancy (most common) respiratory/GI infection, IBD, pregnancy and meds (nitrofuratoin, anti epliptics, TMZ SMX). Treatment is steroids and they do well. The “mystery rash” was eczema herpiticum. The case in clinical quiz #2 was Loeffler’s Endomyocarditis and she got…..steroids and was discharged in perfect condition. It can cause fibrous tissue infiltration of the endocardium.
EMU LOOKS AT: ** Nails, Hair, and the Law**
This month we are out to make a fashion statement- we will talk about systemic manifestations of disease that you can see in the nails and hair. Our second essay is on the Good Samaritan Laws and if my Lawyers (Greg and Sandy) and still reading –I want your comments. The former articles are in Curr Probl Ped Adol Health Care 42:198 and 204. The latter article is from chest 143(6)1774
Hair
These articles are on kids but the diseases are similar in adults- I will try to focus on things that are more common, but it will still come out looking like a list.
Let us start with hair. We do have some folks practicing in areas with poor nutrition; and hair lightening, thinner hair, decurling and brittleness are signs of kwashiorkor and mamarus. Sometimes the hair can have light and dark bands on the same hair. Scurvy can show corkscrew hairs. I do not see the corkscrew here – do you?
Hey – if you do not remember what kwashiorkor is – it is severe protein malnutrition. Marasmus is total malnutrition. Zinc and iron can also cause hair loss – think of this in alopecia arreata.
Medications can lighten hair- if you always wanted to have highlights in your hair try taking acitretin, or chloroquine. Are you a blonde who always dreamed of being a brunette? Cyclosporine can darken hair. Propofol, minoxidil, valproic acid, and verapamil can all cause hair color change.
There are congenital disease that can cause silver hair and gray hair- (gray hair is called canities). The only ones you may see causing gray hair are in tuberous sclerosis and neurofibromatosis.
Have someone with right ventricular cardiomyopathy? They may have wooly hair. So can Caravajal syndrome. Of course, if they have four legs there may be a different diagnosis.
Want to lose some of that hair? Dicoid lupus will do it for you. Want more hair? Dermatomyositis initially may give this. However, stress, thyroid disease, systemic illness, beta blockers, valproic acid, and post-partum states may result in hair shedding.
But the really hairy kids – and folks – that is usually genetic. Here are some interesting names- ever see someone with one eyebrow? That is called synophyrs. If they have that and are very hairy – this could be Cornelia De Lange Syndrome (I think I went out with her in college). However you can also acquire excess hair – mercury poisoning, TB, and porphyria can do this, phenytoin, penacillamine, minoxidil and valproate can do it. So can PCOS, adrenal hyperplasia and taking androgens. And of course there may be a different diagnosis for this too
I think this was the girl I went out with in college.
Nails:
Onychomadesis – yeah that’s the ticket – this is where the nail plate separates from the nail fold. And beside,s you sound real intelligent if you say big words like that. (Yes, delicatessen is another big word too). This can be seen in hand, foot, and mouth disease. (No, not seen in foot in mouth disease). You may also see this after exposure to valproic acid and in Kawasaki’s disease.
Beau’s line. This is a transverse groove very similar to onychomadesis – but it is partial. They can develop due to physiological stress if it is multiple nails. These stresses can be anything – prolonged fever, infection – they usually grow out and disappear. If it is in one nail – it is usually due to local trauma.
Splinter hemorrhages – yeah this is a famous sign of endocarditis, but they hurt in that case, and usually are associated with Osler’s nodes. Painless ones can be seen in vasculitis, trichinosis, polyarteritis nodosa, and scurvy.
Onycholysis isn’t as cool as a word as onychomadesis, but it is similar – it is separation of the distal nail bed from the nail bed. Trauma, infection, thyroid disease, fungal – just look to see if it is one nail, in which case it is probably traumatic or a local process. If it is multiple nails think systemic – or frequent water exposure.
Koilonycia is an even cooler word – these are soft nails which are spoon shaped. These can be idiopathic, or from chronic trauma such as barefoot walking and water exposure. Anemia and hypothyroidism can also cause this.
Leukonycia is whiteness of the nails – this can be from all sorts of genetic problems or from fungi. Punctate white spots are from trauma – you probably have a few on your nails right now.
Transverse leukonychia are bands of white lines that go all the way – horizontally or longitudinally. Trauma, yes, Kawasaki, AIDS, and chemo.
Kenickie sounds the same but he was a character in the movie Grease and has nothing to do with nails – but sounds the same. In case you missed Grease – a lot of sad stories from that movie – Kenickie – played by Jeff Conaway – had drug issues – and the female lead – the oh so beautiful and melodious Olivia Newton John – is battling breast cancer.
White lines – if they are true white lines – this is arsenic tox but can be thallium or lead. These are called Mee’s lines. Muehrcke’s lines are paired white lines and they disappear with pressure on the nail bed - chemo and hypoalbuminemia,
Yellow nail syndrome (no, they are not called Pee’s lines) are seen in pulmonary disease. Blue nails are seen in Wilson’s disease, minocycline, and AIDS and in foxy ladies!
Just dark nails can be from hydroxyurea, chemo, and adrenal insufficiency. However in kids, nail biting can cause this. So can dirty nails.
11. There are Lindsay’s nails and Terry’s nails – the former are seen in Crohn’s disease and the latter in cirrhosis but this is getting boring, so let’s go on to the next topic.
No it isn’t time for Good Sam laws – I liked this article and it was too long for the abstracts section. Yes, it is time to discuss CTS- carpal tunnel syndrome
Gosh, it has been so long since I thought about Secaucus. Good thing that I didn’t
Yeah you know CTS – tingling, numbness, or pain in the distribution of the median nerve – that is the first three digits and half of the fourth. This is three times more frequent in women, and risks include diabetes, obesity, and family history. Hand vibratory tools too – but not using a mouse or keyboard. Your patient will most likely be between ages 40-60. CTS is a progressive problem – early in the course it is a nocturnal problem and patients try to shake it off – the Flick sign! The next step is more impaired sensation, so there is actually less pain, but more weakness, and they may drop things. Later all sensation is lost except in the thenar eminence. Just remember – sudden, severe symptoms of CTS can mean a hematoma in the tunnel – this needs immediate decompression.
There are four tests that may help. Phelen’s (wrist flexed), Tinel’s (tapping over the transverse carpal ligament), MNC test (pressing on the transverse carpal ligament), and hand elevation (elevating both hands for 60 seconds). All are positive if there is pain or paresthesia. All have sensitivities of about 65% and specificities in the high seventies.
So you can try electrodiagnosistic studies – but they hurt and miss up to a third of mild cases. MRI and CT have no place here. Ultrasound might – not so clear yet.
Ddx includes cervical radiculopathy, deQurvains, hypothyroidism, peripheral neuropathy, pronator syndrome, ulnar compressive neuropathy, vibration finger, and wrist arthritis, and carpometacarpal arthritis. However, all of these are pretty different from CTS and you can see the chart in the article to help you rule those out. Cornelia de Lange Syndrome is not in the DDx.
The big question is – is it necessary to prove the diagnosis? Splinting in mild and moderate cases may just be enough. Even more so – one third of the cases resolve spontaneously without doing anything. And in fact – splinting helps whether you do it during the night only or all day. Injection of steroids in the 4 cm proximal to the flexion crease is a good option too, just be careful you do not cause a tendon rupture or nerve injury – if they feel intense pain when you insert the needle – redirect or remove without injecting!!! Steroids by mouth may help – but less than injections and it tends to wear off after 8 weeks. NSAIDs, yes, you heard me right – NSAIDs, diuretics, and vitamin B6 have no role. Nerve gliding physiotherapy helps a lot, but therapeutic ultrasound, and carpal bone mobilization does not help. Acupuncture did not work.
If it is severe, you can consider surgery – which now can be done with an endoscope or with minimal incision. The latter is done under local and with ultrasound guidance, but there is still not enough evidence to stay this is the preferred method. They will need splinting after surgery in any case, and they will need to do the nerve glide stuff. Still, many fail surgery (up to 19%) and some even need surgical revision.
Here is one last essay. I know you are tired. You are probably sleeping now for sure. But maybe that is not sleep- maybe you are really fibrillating – I consider it my fiduciary duty to help you – am I going to be a G